Michael Vita/Miami Dade Gay & Lesbian Chamber of Commerce.'
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 3313&
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
action, decision or recommendation that foreseeably will be heard or reviewed by the ity commission, or a city board or committee. The term
specifically i eludes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ord ance 2004-3435. '
rvriiw~ yr FvtltSTIJ I : (L2St) (First} (M.I)
BUSINE S NAME~AN (Numb ran t t~ r iCjly)~ 3~ I ~ State) (Zip Cod )
SS 1 V I S~ 1~ EGS`-~, She , a~ -1~- [
TELEPHO E NUMBER: FAX NUMBE EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
BUSINES NAM AND DDRESS (Number and-,~,tr 3 i~)~ (State) (Zip Co e)
'S~ ' ~ 3' '•~ o
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is T orpdt'atio Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: `~~J ~ ~~ ~ S
;r
Issue to be lobbied (Describe in detail): ~ ~a 1 ~ ~ l ~ D~
nl. C1TY AGENCIES/INQIVI'DUALS TO BE LOBBfED: Pursuant to city cot~e'~'e~'tio'n 7 e . clud~~~
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an ~ I~
appearance of an impropriety with any City personnel sought to be lobbied -further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIC LQBBY ISSUE::
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A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes No: Are you lobbying on a present or pendina bid for Goods, eauipment or services, or on a
present or pendina award for Goods, eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitied "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes No: Are you lobbying on a pendina application for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
-' , Maps
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of snot-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
Yes ^ No' Are you representing anot-for-profit corporation or entity without special compensation Dr
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
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Form of Identification
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-+: app&~~,°,,~ `~rsonally known (Lobbyist)
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TORE AND STAMP OF NOTARY:
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H~~lorida, County of Miami-Dade
Sworn to and subscribed before me
This day of ~'"~2009
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Signature of Public Notary - ate of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
Produced ID ~ ~`~'-''!'_ ~`~~~~~} ~~ / q~
Form of Identification ~~NNIiIII INb~e~
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^ Personally known (Principal) ,aa~:•• M YCO •;q~'`~,
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State of Florida, County of Miami-Di3~';• ~ ~ ,
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Swom and subscrib d
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Signature of Public Notary - S to of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date Paid
Lobbyist Registration Form received and verified by:
Er'°;~ta°~~,°4a~:~lt~!~~:~oa:~YI~" ~:ar~t~€~~c~~i~yi~¢:~ae~4strx~s-:ne: =~r~r~, x'::~~3~.~up: Revised 02/11/2009
I do solemnly swear that all of tF1e foregoing facts are tad correct and that I have read or am familiar with the
provisions contained in Section 2 of the yt/ami Beac City ode ahd all reporting requirements.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, wwvr.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ _ ~ L
CityClerk@miam ibeachfl.gov
I understand that no later than October 1st of etch year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
tc~mmediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature:
~',~ ~ ~
Date
F:1C~ERlLC1BBYIST1Lobbyist Registration Form 32708.doc